Provider Demographics
NPI:1093155871
Name:MORTENSEN, RISA G (LPC)
Entity Type:Individual
Prefix:
First Name:RISA
Middle Name:G
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4347 NYSTROM WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2531
Mailing Address - Country:US
Mailing Address - Phone:208-431-1889
Mailing Address - Fax:
Practice Address - Street 1:2273 S VISTA AVE STE 190
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-7341
Practice Address - Country:US
Practice Address - Phone:208-343-2737
Practice Address - Fax:208-343-3238
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC 4877101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health